Heart attack
Heart attack is a sudden arisen circulatory failure of the myocardial layer of the heart, the formation of which is due to thrombotic or spastic lesions of the vessels of the coronary segment, followed by necrosis of the myocardium in the trophic lesion.
Clinical death from a heart attack can be formed even during the first minutes from the debut of the clinical symptom complex, and the provocation of a fatal outcome in most cases is the presence of an extensive zone of myocardial infarction. According to the world statistics, acute heart attack takes the prevailing position as an etiopathogenetic factor provoking a fatal outcome in the general population of the population.
Consequences of a heart attack, as a rule, are irreversible, so early verification of this pathological condition and adequate prevention of repeated incidents are extremely important.
Causes of heart attack
A reliable etiological factor in the development of a heart attack, as a manifestation of the pathological changes that occur in various cardiac pathologies, is the atherosclerotic lesion of the vessels that supply the cardiac muscle. In cases where the metric parameters of the atherosclerotic plaque are small, the signs of a heart attack have a transient transient character, and with complete blockage of any segment of the lumen of the coronary vessel, cardiac muscle develops irreversible changes in the form of ischemia and necrosis.
Partial obliteration of the lumen of the coronary vessel most often develops a heart attack at night in the form of a short-term pain syndrome in the projection of the retrograde region. This form of heart attack clinicians describe the term "angina", but these pathological conditions have a number of clinical differences( with a heart attack, the intensity of pain is more pronounced, lasting more than 30 minutes, not stopable by oral intake of Nitroglycerin).Thus, the main risk category for developing a heart attack is patients who suffer from atherosclerotic and ischemic heart disease.
There are non-modifiable risk criteria for developing a heart attack in the form of old age, gender, race to African American race, and genetic determination. To the risk factors that contribute to the development of a heart attack, include the so-called dysmetabolic syndrome( increased levels of atherogenic forms of cholesterol), decompensated diabetes mellitus, low tolerance to physical activity, prolonged use of drugs of a group of non-steroidal anti-inflammatory drugs in high dosage.
Symptoms and signs of a heart attack
The first signs of a heart attack are the appearance of a pronounced prolonged pain syndrome in the chest area, accompanied by a feeling of tightness in the chest and inability to perform full respiratory movements. In some situations, a retrosternal pain syndrome appears after prolonged pain in the area of the upper half of the trunk, neck and shoulder girdle. The classic variant of the chest pain syndrome is long-lasting and can be blunt, aching, cutting, but more often patients describe the condition as "intense burning behind the sternum".Pain syndrome, even with a short flow can be accompanied by severe disturbances in the rhythm of cardiac activity, which is expressed in the form of sensations of interruptions in the work of the heart.
A typical course of a heart attack is impossible without the development of respiratory disorders of varying intensity, manifested in the form of progressive dyspnea, which occurs both after intense physical activity and in a state of absolute physical and psycho-emotional well-being.
The presence of such clinical manifestations as nausea and vomiting can simulate other pathological conditions that have nothing to do with damage to the structures of the cardiovascular system, but these symptoms very often accompany the course of a heart attack. In this situation, the only criterion for conducting differential diagnosis is the absence of a connection between the appearance of these symptoms and the fact of eating. Frequent heart attacks have a very negative effect on the blood supply to the brain structures, which is why patients in the interictal period note marked weakness, inability to perform minimal physical activity and even a brief loss of consciousness.
In addition to the characteristic symptoms that indicate the development of a detailed clinical picture of a heart attack, there is a whole range of manifestations that act as its predecessors. Patients suffering from frequent heart attacks can foresee the onset of this pathological condition and take those medications with a heart attack that allow in a short time to stop the pain syndrome and prevent the development of complications. In each specific case, various clinical progenitor symptoms are observed, but in most cases there is a sharp increase in heart rate, insomnia and a feeling of "inner shivering".
When establishing a preliminary diagnosis of a heart attack, a doctor should adhere to a differentiated approach to collecting an anamnesis, clarifying patient complaints and evaluating the criteria for objective examination, since there is a whole range of nosological forms accompanied by the development of similar clinical symptoms. Thus, with intercostal neuralgia, there is a pronounced pain syndrome in the chest, but in this situation, as a rule, there is no correlation between the development of pain syndrome and psychoemotional or physical exertion, which occurs in a heart attack. Despite the apparent differences in the symptomatology of these conditions, the basic test is nitroglycerin, which stops the pain syndrome in a heart attack in the shortest time and does not have any effect on the pain syndrome in intercostal neuralgia.
To conditions aggravating the course of a heart attack and provoking repeated episodes of acute coronary insufficiency, provided there are no preventive measures, include: various forms of cardiac rhythm disturbance, cardiogenic shock and decompensated heart failure.
In most situations, a vivid clinical picture and data of objective examination of the patient allow the preliminary diagnosis of a "heart attack" to be correctly established in the pre-hospital stage, but the data of the instrumental survey are reliable criteria to determine the cause of the development of this life-threatening condition.
To establish the presence of ischemic myocardial damage as a pathogenetic basis for the development of a heart attack allows routine electrocardiographic examination, with specific electrocardiographic signs of both ischemia and the development of irreversible necrotic changes in the myocardium. Echocardioscopy with a heart attack has practically no practical application, since in the early period of myocardial ischemia, there are no specific signs of damage to the heart muscle that have pathognomonic ultrasound sciology. The only laboratory method for diagnosing myocardial infarction as a background condition for the development of a heart attack is the determination of specific biological markers( troponins and creatine kinase), the level of which increases significantly with necrotic changes in the myocardium.
First aid for a heart attack
If the first signs of a heart attack are revealed, it is necessary to provide the patient with the maximum coordinated medical care even before the arrival of the ambulance team, since this pathological condition is classified as rapidly progressive and prone to severe complications up to a lethal outcome.
Priority measures to assist a patient with a long acute pain in the chest region, which is the most important clinical criterion for a heart attack, is the patient's taking a single therapeutic dose of Nitroglycerin in aerosol or tablet form. In the absence of a visible positive effect in the form of arresting a pain attack and reducing the progression of dyspnea, it is permissible to repeatedly take a single dose of Nitroglycerin after 5-10 minutes.
In a situation where a heart attack develops in the patient for the first time, it is necessary to call a team of emergency medical care with subsequent hospitalization in the profile hospital, even if the pain relief is completely eliminated at the prehospital stage. Indications for hospitalization of patients with a diagnosed pathogenetic form of a heart attack( myocardial infarction, unstable angina, acute coronary syndrome) is a non-stopable pain syndrome and the progression of hemodynamic and respiratory disorders.
In order to eliminate the pathogenetic link of atherosclerosis and emergency lysis of the available thrombotic masses, patients on a pre-hospital stage are recommended oral Aspirin in a single dose of 500 mg. It is necessary to notify the doctor of the ambulance team about taking medicines at the prehospital stage, indicating not only the pharmacological group, but also the dosage. The composition of emergency therapy of a heart attack includes masochka oxygen therapy.
The relief of a pronounced prolonged pain syndrome in a heart attack is realized using the method of neuroleptanalgesia drugs( agents combining analgesic and neuroleptic effects).For this purpose, a 0.005% solution of Fentanyl in a dose of 1 ml should be used, as well as a 0.25% solution of Droperidol in a single dose of 2 ml by the intravenous-jet method. In a situation where intense pain syndrome is accompanied by increased excitability of the patient with a heart attack, it is advisable to use intravenous drug( 1% Morphine solution in a dose of 1 ml).
Treatment of a heart attack
Treatment measures used in a heart attack should be pathogenetically justified and etiologically directed. Drug treatment methods differ according to the principle of long-term admission. There are medicines for emergency medication correction of a heart attack, as well as for lifelong maintenance therapy.
Due to the fact that the formation of an obstruction to the normal blood flow through the coronary vessels due to the development of blood clots in the lumen is the basis for the development of a heart attack, the removal of thrombotic masses by any possible method is an indispensable condition for improving the patient's condition and reducing the risk of developing irreversible myocardial changes. The most effective method of eliminating intraluminal obstruction of the vessel is performing angioplasty in the form of percutaneous coronary intervention. The effectiveness of this method directly depends on the timeliness of its use( no more than 90 minutes from the debut of a heart attack).
Numerous randomized trials have proven the absolute inefficiency and inexpediency of using percutaneous coronary shunting to patients after more than three days from the onset of a heart attack. In 10% of cases after the angioplasty there is a complication in the form of restenosis, which is formed within half a year from the application of surgical treatment. In order to exclude the development of restenosis, a technique for the use of stents with a special coating( sirolimus, paclitaxel) has recently been developed. All patients who have been implanted with a stent are recommended not only in the postoperative period, but also for life to take Klopidogrel, 1 capsule in the evening.
In a situation where there is no possibility of performing an operative intervention, an alternative method is to use an adequate scheme of thrombolytic therapy with the use of drugs that are directed at lysis of thrombotic masses and the restoration of normal blood flow. It should be borne in mind that the effectiveness of thrombolytic therapy is limited to time intervals, that is, it is necessary to use drugs of this category in the first three hours from the onset of a heart attack. Restrictive factors for the use of thrombolytic therapy are: the elderly age of the patient who has anamnestic data for the stroke, pregnancy and acute massive blood loss, the patient's stomach ulcer, long-term use of anticoagulants.
In order to reduce the risk of progression in the formation of thrombotic complications, as well as preventing the formation of new thrombi, it is advisable to combine the appointment of anticoagulant and antiplatelet agents. Currently, in terms of emergency treatment of a heart attack, Akteliz, Metaleze( 100,000-25,000 units) is used. The most severe and frequent complication of the use of drugs of this pharmacological group is the development of hemorrhagic type of stroke.
In order to stimulate protein synthesis and improve metabolic processes in the body, the intensification of the scarring process in the necrotic zone uses drugs from the group of anabolic steroids( Retabolil once in 10 days 5% solution in a dosage of 1 ml, Fenobolin intramuscularly at a dose of 1 ml of 1% solution 1once a week).Absolute contraindications to the use of drugs of this pharmacological group are any cancer, pregnancy and severe hepatic insufficiency.
Patients who develop a heart attack against a background of congestive heart failure are advised to use an adequate scheme of diuretic therapy with a parenteral route of administration( Furosemide intravenously 20 mg 1 -2 times a day) in addition to standard medical treatment.
Prevention of heart attack
The prognosis for a heart attack directly depends on the preventive measures that the patient applies in the after-attack period. The preventive measures used are directed mainly at preventing a repeated episode of a heart attack, and also reducing the risk of developing a lethal outcome. According to statistical data, the development of acute coronary syndrome is provoked by a patient's non-compliance with the recommendations of the treating physician in full with regard to the prevention of a heart attack. In addition, provided there is no preventive treatment, a heart attack can provoke the development of severe forms of cardiac rhythm disturbance and damage to the valvular heart apparatus.
It should be taken into account that in some situations the patient after the episode of a heart attack can develop a painless form of myocardial ischemia that is not accompanied by the formation of classical clinical symptoms and at the same time has a high risk of developing cardiovascular complications, up to a lethal outcome.
As a preventive measure, dynamic monitoring of blood pressure indices should be considered and keeping these indicators at the level of not more than 140/90 mm Hg, for which all patients suffering from heart attacks in the presence of hypertension are recommended regular intake of antihypertensive drugs andCompliance with the rules for the correction of eating behavior( limiting the use of salt and compliance with the water regime).As an antihypertensive drug should be given to the group Beta-blockers( metoprolol in a daily dose of up to 200 mg orally), which are the drugs of choice in preventing the development of a second episode of myocardial infarction and heart attack. The mechanism of the positive effect of these drugs is realized by reducing the need for cardiac muscle in oxygen, reducing the heart rate.
Recent randomized studies have confirmed the positive effect on the life expectancy of patients with a history of a heart attack, antiplatelet agents, provided they receive a regular lifelong admission( Clopidogrel, Cardiomagnin once a day, orally).In addition, the drugs of the statin group with prolonged intake level the possibility of progression of atherosclerotic vascular lesions of the coronary segment, which significantly reduces the risk of developing repeated episodes of a heart attack( Atorvastatin in a maintenance dose of 20 mg for at least six months orally).When prescribing statin drugs to the patient, their hepatotoxicity should be taken into account, and therefore, a preliminary study of the hepato-biliary system is recommended, as well as taking the drug with a permanent laboratory control of hepatic samples.
Heart attack - which doctor will help ?At the slightest suspicion of a heart attack, you should immediately seek advice from such specialists as a therapist or cardiologist.